Active appendiceal bleeding recorded by choledochoscopy

Active appendiceal bleeding recorded by choledochoscopyA 34-year-old man presented with painless hematochezia for 3 days.Colonoscopy performed at a secondary hospital was advanced to the terminal ileum, where a small amount of fresh blood was observed.The patient was initially diagnosed with small intestinal bleeding.On day 4 of illness, hematochezia persisted, and he was referred to our institution.Computed tomography angiography performed on admission, and no contrast medium was observed within the appendix on plain CT ( Fig. 1 a); punctate contrast enhancement was noted during the arterial phase ( Fig. 1 b), with further accumulation in the venous phase ( Fig. 1 c).However, due to the extreme rarity of this finding, the intraluminal contrast within the appendix was not recognized during the initial image interpretation.On day 5, the patient continued to pass small amounts of bloody stool.On day 6, single-balloon enteroscopy was performed.On advancing the scope into the distal ileum, approximately 40 cm proximal to the ileocecal valve, yellowish intestinal fluid was encountered.Upon withdrawal to the cecum, active blood flow was observed emanating from the appendiceal orifice.A colonoscope was introduced into the cecum, and a choledochoscope was advanced through the biopsy channel.Bleeding from an appendiceal ulcer is not continuous but rather manifests as sporadic, pulsatile bleeding or oozing ( Video 1).Laparoscopic exploration revealed the appearance of the appendix is basically normal.Appendectomy was performed, and gross examination of the resected specimen demonstrated an ulcer located in the mid-portion of the appendix.Upon gross examination after appendiceal resection, an ulcer within the appendix was identified ( Fig. 2).The patient experienced no further bleeding after the surgery. Fig. 1 CT images of appendiceal hemorrhage.a CT plain scan of the appendix.b Arterial phase of the appendix.c Venous phase of the appendix. Fig. 2 Laparoscopic and postoperative images of the appendix.a Laparoscopic exploration of the appendix.b Mucosal ulcer of the appendix.c Close-up observation of the appendiceal ulcer.